Provider Demographics
NPI:1710650940
Name:JORDAN, MYKALA
Entity Type:Individual
Prefix:
First Name:MYKALA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1N463 INGALTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-2022
Mailing Address - Country:US
Mailing Address - Phone:619-922-9693
Mailing Address - Fax:
Practice Address - Street 1:10 MARTIN AVE STE 225
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6590
Practice Address - Country:US
Practice Address - Phone:630-355-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-25
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085.008678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty